title: Complications associated with prolonged hypertonic saline therapy in children with elevated intracranial pressure.
abstract: OBJECTIVE
  Safe upper limits for therapeutic hypernatremia in the treatment of intracranial hypertension have not been well established. We investigated complications associated with hypernatremia in children who were treated with prolonged infusions of hypertonic saline.
  
  
  METHODS
  Retrospective chart analysis.
  
  
  METHODS
  PICU in university-affiliated children's hospital.
  
  
  METHODS
  All children from 2004 to 2009 requiring intracranial pressure monitoring (external ventricular drain or fiberoptic intraparenchymal monitor) for at least 4 days who were treated with hypertonic saline infusion for elevated intracranial pressure and did not meet exclusion criteria.
  
  
  METHODS
  Continuous hypertonic saline infusion on a sliding scale was used to achieve target sodium levels that would keep intracranial pressure less than 20 mm Hg once the conventional therapies failed.
  
  
  RESULTS
  Eighty-eight children met inclusion criteria. Etiologies of elevated intracranial pressure included trauma (n = 48), ischemic or hemorrhagic stroke (n = 20), infection (n = 8), acute disseminated encephalomyelitis (n = 5), neoplasm (n = 2), and others (n = 5). The mean peak serum sodium was 171.3 mEq/L (range, 150-202). The mean Glasgow Outcome Score was 2.8 (± 1.1) at time of discharge from the hospital. Overall mortality was 15.9%. Children with sustained (> 72 hr) serum sodium levels above 170 mEq/L had a significantly higher occurrence of thrombocytopenia (p < 0.001), renal failure (p < 0.001), neutropenia (p = 0.006), and acute respiratory distress syndrome (p = 0.029) after controlling for variables of age, gender, Pediatric Risk of Mortality score, duration of barbiturate-induced coma, duration of intracranial pressure monitoring, vasopressor requirements, and underlying pathology. Children with sustained serum sodium levels greater than 165 mEq/L had a significantly higher prevalence of anemia (p < 0.001).
  
  
  CONCLUSIONS
  Children treated by continuous hypertonic saline infusion for intracranial hypertension whose serum sodium levels exceeded certain thresholds experienced significantly more events of acute renal failure, thrombocytopenia, neutropenia, anemia, and acute respiratory distress syndrome than those whose sodium level was maintained below these thresholds.
authors.affiliation: Division of Neurosurgery, University of California, San Diego Medical Center, San Diego, CA, USA. dgonda@ucsd.edu
authors.forename: David D
authors.initials: DD
authors.lastname: Gonda
authors.forename: Hal S
authors.initials: HS
authors.lastname: Meltzer
authors.forename: John R
authors.initials: JR
authors.lastname: Crawford
authors.forename: Mary L
authors.initials: ML
authors.lastname: Hilfiker
authors.forename: David K
authors.initials: DK
authors.lastname: Shellington
authors.forename: Bradley M
authors.initials: BM
authors.lastname: Peterson
authors.forename: Michael L
authors.initials: ML
authors.lastname: Levy
mesh_terms: D000293:Adolescent; D000740:Anemia / Q000209:etiology; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D006955:Hypernatremia / Q000139:chemically induced / Q000150:complications* / Q000175:diagnosis; D007223:Infant; D019586:Intracranial Hypertension / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D009503:Neutropenia / Q000209:etiology; D012372:ROC Curve; D051437:Renal Insufficiency / Q000209:etiology; D012128:Respiratory Distress Syndrome / Q000209:etiology; D012189:Retrospective Studies; D012462:Saline Solution, Hypertonic / Q000009:adverse effects* / Q000627:therapeutic use; D013921:Thrombocytopenia / Q000209:etiology; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D012462:Saline Solution, Hypertonic